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HomeMy WebLinkAbout0053 CAPTAIN ALDEN'S LANE - Health 53 :C'aptain',�Al ae'n;,S — � fs Osterville A- 146 - 085 i i '1 i a i I i r ' Commonwealth of Massachusetts Title 5 Official Inspection Form a.. ° j� l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 53 Captain Alden's Lane r , Property Address Manuela Russmayer Owner Owner's Name information is Osterville V MA 02655 11/09/2020 'required,for_every - page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered,in any a way. Please see completeness checklist at the end of the form. Iripor3aht:When filling out forms A. Inspector Information •. �l.a /yp3a' on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Company Address Teaticket Ma. 02536 H City/Town State Zip Code 508-280-3356 SI3938 _ , •..G . y Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined •_:_ � that the system: 1. ® Passes -'~ 2. ❑ Conditionally Passes ,aria, 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails NNI Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of lr!,, 7.2, 10,000gpd or greater, the inspector and the system owner shall submit the report to the a k ro priate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the i conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 f I � i I Commonwealth of Massachusetts p Title 5 Official Inspection Form y.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 53 Captain Alden's Lane Property Address i k - Manuela Russmayer , Owner Owner's Name information is requi red-for every Osterville MA 02655 11/09/2020 t. page: CitylTown State Zip Code Date of Inspection - C. Inspection Summary. Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: 1 have not found any information which indicates that any of the failure criteria described, 3 ,, in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: — �n`%• lia�tc .. .. . This 3 bedroom home has an H-10 1000 gallon septic tank with an H-20 D-Box feeding 26-infiltrators.- At the time of the inspection no visible failure criteria was found. The septic tank is scheduled to be pumped 11/12/2020. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be -_ replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. yak '-';�'.i{�`;'�,P.'i`r.. Check the box for"yes", yesn, "no" u or not determined" (Y, N, ND) for the following statements. If not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. dloioe ❑ Y ❑ N ❑ ND (Explain below): by - t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 by Commonwealth of Massachusetts lip Title 5 Official Inspection Form li Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o u - 53 Captain Alden's Lane "=`{ Property Address Manuela Russmayer Owner Owner's Name information is required for every Osterville MA 02655 11/09/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution.box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System-will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): _ ❑ distribution box is leveled or replaced [IY ElN ❑ ND (Explain below): r : _ Bpi k't,J i 0X•,::, ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, j py safety and the environment: 11 _ t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of,18 A`=`•'s Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Captain Alden's Lane Property Address Manuela Russmayer Owner Owner's Name in ormation is -.. required`nfor every Osterville MA 02655 11/09/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public--health; --_- - } safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. S ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory;`foHecal ' coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis mast be attached to this form. c. Other: is 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No f ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool , t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pager4`ofd18;, iY> •tc - r Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Captain Alden's Lane Property Address Manuela Russmayer Owner Owner's Name information is required for every Osterville MA 02655 11/09/2020 page. City/Town State Zip Code Date of Inspection .. r-. C. Inspection Summary (cont.) 7J�TC'e _rij42>S _ --s,t -wi 4) System Failure Criteria Applicable to All Systems: (cont.) r z Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water,, up ply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply,_,,t El Z well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, .. provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] , The system is a cesspool serving a facility with a design flow of 200'0 gpd 'Y `} ❑ ® 10,000 gpd. J tE.., £,T A„ = ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No { �V'clPd F ❑ ❑ the system is within 400 feet of a surface drinking water supply .,, ' ct'� arc U r' �" ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply-' ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Captain Alden's Lane �+•.,r;.;�fa.,r,;,; , Property Address "t ; ;yV Manuela Russmayer Owner:' Owner's Name ";It information is required for every Osterville MA 02655 11/09/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: `+ "` + Yes No czt?U�i. ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection?Were as built plans of the system obtained and examined? (If they,were not ® ❑ available note as N/A) .. .i O , ® ❑ Was the facility or dwelling inspected for signs of sewage back up? .- If:Tt f�'c'altC kik "'i tn,a - ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with V ...� information on the maintenance of subsurface sewage disposal systems? proper 9 p Y _.. The size and location of the Soil Absorption System (SAS) ori,tl eaife;liar been determined based on: " ' r ® El Existing information. For example, a plan at the Board of Health. IF Fc,li i';IiniC ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 4 : t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 1 11 8 i;;* F. t. C Commonwealth of Massachusetts �*. Q I i�F v =. I1? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 53 Captain Alden's Lane Property Address Manuela Russmayer Owner Owner's Name information is required for every Osterville MA 02655 11/09/2020 page''.^`" City/Town State Zip Code Date of Inspection D. System Information F s� 1. Residential Flow Conditions: f + Number of bedrooms (design): 3 Number of bedrooms (actual): ' DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: 4 " e J� Number of current residents: 1' Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes_® No information in this report.) Laundry system inspected? ❑ .Yes ® No ' Seasonal use? ❑ Yes��® No k Water meter readings, if available last 2 ears usage town.water -- 9 ( Y 9 (gpd)): . Detail: In 2019-96,000 gallons were used and in 2018- 198,000 gallons were used Sump pump? ❑ Yes-E No Last date of occupancy: occupied -» Date` w btii t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 53 Captain Alden's Lane _. V - Property Address ' x, Manuela Russmayer M Owner- Owner's Name : - ALLa.r: information is Osterville MA 02655 11/09/2020 d for every require page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) ; ,w ..Z Basis of design flow(seats/persons/sq.ft., etc.):Owner E,r it?or;"„alit. Grease trap present? ❑ Yes'"❑ -No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No r. Water meter readings, if available: Last date of occupancy/use: DateNo - - r,f - Other(describe below): ' F, • 3. Pumping Records: Source of information: *� _ Was system pumped as part of the inspection? ❑ Yes No ~ If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 16 j ! err 3 }i E t.�t%r` ;tit• . .r Commonwealth of Massachusetts -61 Title 5 Official Inspection Form V S {f , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............� 53 Captain Alden's Lane Property Address Manuela Russmayer Owner Owner's Name information is Osterville MA 02655 11/09/2020 required for every . page.'.:"-r Cityrrown State Zip Code Date of Inspection D. System Information (cont.) , < A 4. Type of S yytem: ;16 ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) _• ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of-lafdst inspection of the I/A system by system operator under contract X'4LA4 o C ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: New leaching 2013 Were sewage odors detected when arriving at the site? ❑ Yes � No 5. Building Sewer(locate on site plan): " J Depth below grade: 22"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. At 0 :. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. !% 53 Captain Alden's Lane V Property Address x. r12, w Manuela Russmayer - Owner Owner's Name information is Osterville MA 02655 11/09/2020 required for every _ --- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ otlhr' ;explain) If tank is metal, list age: years .3 = Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3511 1„ Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structuralinfegn y,- liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping--co."y" based on the future use of the home. At the time of inspection the liquid level was at working-level- and the tee's were in place. t5insp.d6c-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pagekl,Q,of 1`8z,,J,a ':} r I r;ttrr<[ Commonwealth of Massachusetts Title 5 Official Inspection Form t l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Captain Alden's Lane Property Address Manuela Russmayer Owner Owner's Name information is required for every Osterville MA 02655 11/09/2020 page: Cityrrown State Zip Code Date of Inspection D. System Information (cont.) �.�,�:. `tits �� ��•: _; 7. Grease Trap (locate on site plan): - Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness t..i.Esc•:;:�°,, �'J y�f;i•i�':>1.d 1>;:'" { - Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 4k �yYr�r - • 4 IC lf�5_._._.. 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Captain Alden's Lane - Property Address Manuela Russmayer -- Owner:_ Owner's Name information is required for every Osterville MA 02655 11/09/2020 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ..":.❑__Noy 9. Distribution Box (if present must be opened) (locate on site plan): "`rye 0 Depth of liquid level above outlet invert J Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. `.mil rq 1- t51nsp.c3oc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts _-- .- Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Captain Alden's Lane Property Address Manuela Russmayer Owner Owner's Name information is required for every Osteryille MA 02655 11/09/2020 page.'- "� City/Town State Zip Code Date of Inspection D. System Information (cont.) Is 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): .�. 'yl�.= .._ .. _. * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 20, Infiltrators ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Captain Alden's Lane Property Address - - - Manuela Russmayer Owner Owner's Name information is required for every Osterville MA 02655 11/09/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): - At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): <� Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts OF Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Captain Alden's Lane u� Property Address Manuela Russmayer Owner Owner's Name information is required fo Osterville MA 02655 11/09/2020 r every page.- "".� Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 6• G .,. y s fin.. •..,,. ---. .. If qf !C'e xr'? _. ._. .. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 a Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 011 53 Captain Alden's Lane Property Address Manuela Russmayer Owner .. Owners Name information is Osterville MA 02655 11/09/2020 required;for every page. Cityrrown State Zip Code Date of Inspection f D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate-where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately - - - -- ii��•:•rs«:ice a;irf r for41 a I , _ ,rr• ... a a 4 A Frpu1 +rrts t,y �e Z:.n DooR r -�orr i t a � . 3._--33 r 'i f t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18. j Commonwealth of Massachusetts Title 5 Official Inspection Form m aI e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Captain Alden's Lane Property Address Manuela Russmayer Owner Owner's Name information is required for every Osterville MA 02655 11/09/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 15. Site Exam: ' ® Check Slope I ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 plus feet feet Please indicate all methods used to determine the high ground water elevation: " ry. ..:( ElObtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-.(attach documentation) ElAccessed USGS database -explain: I You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. p arie.. _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Captain Alden's Lane Property Address �. Manuela Russmayer ---- , Owner Owner's Name I information is Osterville MA 02655 11/09/2020 ' required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate in or,T1,, _ - 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included _ irtiti;r,F. _ , rt:'s t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 lrir'�.Cfik�' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for-Voluntary Assessments ,M 53 Capt Aldens Lane Property Address Jeffrey& Deb Lieberman Owner Owner's Name -a information is required for every Osterville Ma 02655 3-23-17 page. City/Town State Zip Code Date of Inspection u Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 1aQ46— on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation reb Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI 13640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority: 3-23-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System /•Page 1 of 17 / o V V Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Capt Aldens Lane Property Address Jeffrey & Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 53 Capt Aldens Lane M Property Address Jeffrey & Deb Lieberman Owner Owner's Name information is Osterville Ma 02655 3-23-17 required for every - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): _ ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ,ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15:303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: I ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Capt Aldens Lane Property Address Jeffrey& Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within'a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Capt Aldens Lane Property Address Jeffrey& Deb Lieberman Owner Owner's Name - information is required for every Osterville Ma 02655 3-23-17 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® ` Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 'Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Z . Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. or, Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone Il of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Capt Aldens Lane Property Address Jeffrey & Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ 0 Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330gpd t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 53 Capt Aldens Lane Property Address Jeffrey& Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2015- 14,000gallons 2016- 14,000gallons Sump pump? ❑ Yes ® ' No Last date of occupancy: Weekends Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 4 , Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Capt Aldens Lane M Property Address Jeffrey& Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- not pumped in last 3 years Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? . Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑. Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 53 Capt Aldens Lane Property Address Jeffrey &Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23=17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: New SAS added to existing tank in 2013 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): _ Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence,of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 101, feet Material of construction: ® concrete . ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: j years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 1� W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 53 Capt Aldens Lane Property Address Jeffrey& Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to.bottom of outlet tee or baffle 31" Scum thickness - 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4.153 Capt Aldens Lane Property Address { Jeffrey& Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at.time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete El metal El fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping:' Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 CaP t Aldens Lane Property Address Jeffrey& Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 011 Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was in working order at time of inspection with no sign of back up. Pump Chamber(locate on site plan): I Pumps'in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 53 Capt Aldens Lane Property Address Jeffrey & Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: - ❑ leaching galleries number: ❑ Teaching trenches number, length: . 0 leaching fields number, dimensions: 20ARC36's 11.52'x25' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Capt Aldens Lane Property Address Jeffrey & Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I, r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 53 Capt Aldens Lane Property Address Jeffrey& Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t '37111 ` i FRONT' l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 53 Capt Aldens Lane Property Address Jeffrey& Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high groundwater: No GW 132" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12-18-12 Date El Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Capt Aldens Lane Property Address Jeffrey& Deb Lieberman Owner Owner's Name information is required for every Osterville Ma 02655 3-23-17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I� TOWN OF BARNSTABLE CATION .S3 AtOC4,5 Lfwe SEWAGE# 'b10/3 00-�r ULAGE O5(ery (L ASSESSOR'S MAP&PARCEL Nd- INSTALLER'S NAME&PHONE NO. �, l`1 1�5 rr� - �-08-LQB-S5.1 SEPTIC TANK CAPACITY 11000(34. Ce,(,t,I6Ug)' LEACHING FACILITY:(type) A,�c3�S tY;,10 1 (size) �A NO.OF BEDROOMS -3 OWNER �Aa�(�S �AM M!}1-f-T- PERMIT DATE:�.3"�6(3 COMPLIANCE DATE: TAq- 30 t.3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY e ZW^ Frown. t-Z' Teas- A %OGR 3 a s 4 � ' -- / — a9 3 7 d`-.3 33 , No. &X, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN-OF BARNSTABLE, MASSACHUSETTS Yes \ ftpliration for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair(11) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. $3 CFr,Pr- k%01Z M5 � Owner's Name,Address,and Tel.No. 4 n 9- C�s'('�rvil`e 'DP'w;tLS +'Deborae{ ttAMo4nT A86-r576 Assessor'sMap/Parcel 1 ti6 / 85, 3t3-tTt- Installer's Name,jdress,aqd Tel.Nqq. . n Designer's Name,Address,and Tel.No. iset,et 0.GQ l�. stt✓ S �- B`t'Pc,na( . v s-rr_r,,:lj. y�8-55�Q Type of Building: Dwelling No.of Bedrooms 3 Lot Size / S,o00 ± sq.ft. Garbage Grinder(Alp Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 3 5,S.a o gpd Plan Date TEF C, k 8 j&O t a Number of sheets Revision Date Title Size of Septic Tank 14696641, /y I�7o�Q Type of S.A.S. i9RC 3 a W-a.D Description of Soil T Nature of Repairs or Alterations(Answer when applicable) -?y/h i`l pJCt S l[ i ✓E� H r"h s C- Ac',..j pis�. 6 ( A a o A2c 3 6' - ��ao ,:,� �. /A sa`&,,-c ax F,Flo/ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f Health. i n Date Application Approved by Date Application Disapproved by Date for the following reasons PermitNo.gKI/ '� Date Issued Fee THE COMMONWEALTH OF MASSACHUSETTS, Entered in computer: PUBLIC HEALTH DIVISION P,76WI�F�;OF BARNSTABLE, MASSACHUSETTS Yes t 21ppliLation for 33isposal ,4pstem Construction permit Application for a Permit to Construct( ) Repair(k/ Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 5-3Cc�+'Z • �= `i 5 L r-i. Owner's Name,Address,and Tel.No. 4 0') C75icrv�l�r 3JAnliclS + ij�Isc��rF ttA+Nlr1.,T f��� Assessor's Map/Parcel 3�l T,r c: L (', (_ ,� n Installer's Name',Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size / 5�Goo ± sq.ft. Garbage Grinder(ivp Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -3 3 n gpd Design flow provided 3 5-5.3 O gpd Plan Date Me c,, �R j l G 1 Number of sheets Revision Date Title Size of Septic Tank 4onb 6 AL /=K t5^i i�rG Type of S.A.S. hjj'C ,3/ 0 Description of Soil Nature of Repairs or Alterations(Answer when applicable) y A/j � t t 1� P f(�S I r n c �d t 0 01 Gc) &2c Z s "//'�G frl �1 �/, 1 t✓ �( �S�f="r�0� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Date Application Approved by �/I Date r Application Disapproved by Date for the following reasons .:,.Permit No. --" Date Issued • . THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compriante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired((�' Upgraded( ) Abandoned( )by f F % at — ) has been const ucted i accord (e with the provisions of Title 5 and the for Disposal System Construction Permit I Ked Installer n�l T_u c tj U_C C �f Designer r2�2= f - - #bedrooms ,� Approved designs flow ? j, �0 gpd The issuance of this permi shal not be construed as a guarantee that the system wil/function 'g.ed. Date Inspector -� NO. /7 Fee 11 f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 3Disposal *pstrm Construction Permit - Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at ('��j�/ i a I i)4` S ,n j n l/F and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructimy must Ife completed within three years of the date of this permit. Date Approved by V I JAN/11/2013/FRI : 1 : 11 Alit SandwichTownOff ices FAX No. 1 5C8 833 OC18 P. 002 'own 'of Barnstable Regulatory Services Thomas F.Geiler,Director ° over U, \� Public Health Division Thomas McKean,Director 200 Main Street,Ryannis,NIA 0160� Office: 30S-362--16,W Fax: 503-7 0-6304 installer& Designer Certification Foram Date: L�11 1 Sewage Perinit# 0 3 Y00 Assessor's lylapTareel I' 09 Designer: Installer: ru Pa_ �I Address; address: Tovid S 6- � JAB W►Gt�- '�"f �a bcti���c — on - was issued a perrnir to install a (date) (installer) septic Systery at %,.53 GA-1pr• lyl�06'AJ5 based orz a design drawn by (address) 15 / dated {Lesigner) I certt�j that the septic sysrem referenced above was installed substantially aecordina to the design. which magi include rr{irlor approved changes such as lateral reloc, on of ti, distribution box and;cr septic tank. I certify that the septic syste;r, referenced above was installed with major changes (i.e. ti greater than 10' late�rai relocation of the SAS or any vertical relocation of any component Of the septic sysrem) but in Fccordance with State & Local Regulations: Plan mvisien or certified as-built by designer to follow. or A M. r, M R � ("Caller's Si;rlarure) � 140 1STI 1 1 �NITAO oil (Designer's Sior`ature) (Affix Designer's Stamp.Here) PLEASE, RETURN TO BA IZ ABLE PUBLIC HEALT14 DIVISION. CERTIFICATE OF CONIPL1A�VCE WILL NOT BE ISSUED UNTIL BOTH THIS FORNI AND AS-BUILT CARD ARE RECIh IVED BY THE BARNSTABLE PUBLIC HEALTH D(VISIOV. TH,!k`X YOU. Q:Heil 1h/8,-pric•DeSigner Cerrificacion Form 3-2".!doe a - I - Town of Bk stable. P#�3 �' Department of Regulatory Services, . ' BLir. Public Health Division Bate �� J prnvs s63q. ems$ 200 MaiwStreet,Hyannis MA 02G01'" - - ~lFDMy'tF ' �}� f j Fee Pd. " Date Scheduled. f Time Foil Suitability �lssessm nt, or �` e Disposal Performed By' t\ ' Witnessed By: 'Aa j LOCATION & GENERAL INFORMATION Location Address L N•i Owner's Name; M - c.J Sfie�r v-i f l e A0, I Address S lvr\KQ Assessor's Map/P4rcel: Engineer's Name ��r(,v/� NEW 60NSiRU!tI ON' REPAIR Telephone# �S 36673311 Land Use k �'4�GW Slopes(3'0) Surface Stones Na N� 3 V Distances from: `Open Water Body y ft Possible Wet!Area b ft Drinking Water Well _ ! ft Drainage Way. `'0 ft. Property Line ]O_ft Other' SKETCH:(Streetname,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) t . I Depth to Bedrock Parent material(geologic) I Depth to Groundwater. Standing Water in Hole:' / _ i Weeping from Plt Face Estimated Seasonal Nigh Groundwater I1 ! — DtTERMINATION FOR SEASONAL BIGH WATER TOO. Method Used: I' ! io: Depth Clb�served standing hole: Depth to salt ingttlts: in os. e of obs.holes itl. ©raundwnter�1d)unttnent Depth toiweeping from sid ! ! _ Adj.factor.,,.— AdJ,C7rnundwnter].evel.,,Level— ate:Well# Reading Date Index Well level PERCOLATION TEST Date_e, T nee__,___. Observation Hole# Time at 6" -= Depth of Pere + Start Pre-soak Time.@ 6 Time(9"-6„) End Pre-soak ! ' Rate MinJlnch - ' L Additional Testing Needed(YIN) Site Suitability Assessment Site Passed X Site Failed: Original: Publicle'alth Division Observation Hole Data To Be Completed on Back ***If percolafiiOn test is to be condiacted within 100' of wetland,.-You must first notify the Barnstable,C44servation DiNision at least one (1) week prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth•from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel DEEP OBSERVATION HOLE LOG Hole# "Y Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel) ' l2`' rc� 31V 11 � 11aS DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horiz Soil Texture Soil Color Soil . Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, ra 1 Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No 'J Yes Within 100 year flood boundary No-7 Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist,in all areas observed throughout the area proposed for the soil absorption system? V 6 If not,what is the depth of naturally occurring pervious material? Certification I certify that on l! C (date)I have passed the soil evaluator examination approved by the Department of Environ entlProtection and that the above analysis was performed by me consistent with the required..raining,expertise and experience described in 3:10 CUR 15.017. ( Signature �.� � '� "� Date +� Q:\.SEPTIC\PERCFORM.DOC Town of Barnstable Barnstable Regulatory Services Department j e"aC BARNsrABLE, MASS. s i63q. Public Health Division �A �e rf0 Mpg a 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean;CHO CERTIFIED MAIL # 7008 3230 0002 5178 2855 December 28, 2012 - Mr. &Mrs.Daniel Hamant , P O Box 951 L Osterville, MA 02655 t i ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLES The septicY P s stem located at 53 Captain Alden's Lane .Osterville MA was last inspected on 11/14/2012, by James M, Ford a certified septic inspector for the Sate of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: e System is in hydraulic failure. You are ordered to repair or replace the septic system within sixty(60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement.action. PER ORDER OF THE BOARD OF HEALTH. Thomas cKean, R:S., CHO. Agent of the Board of Health ` i i Q:\SEPTIC\Letters Septic Inspection Failures or.Future Eval\53 Captain Alden's Ln.,Ost.Dec 2012.doc. 1 Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=9541 Logged in As: Parcel Detail etai4 Monday, December 31 2012 - Parcel Lookup Parcel Info Parcel ID 146 085 Developer I Lot, LOT 6 Location 53 CAPTAIN ALDEN'S LANE I Pri Frontage 165 , Sec Road I Sec Frontage village OSTERVILLE I Fire District'C-O-MM , Town sewer exists at this address No I Road Index 0234 Asbuilt Septic Scan: 146085_1 Interactive I . Map ti I ai i 146085_2 Owner Info Owner HAMANT, DANIELS& DEBORAH E I Co-Owner Streets P O BOX 951 I Street2 City OSTERVILLE I State MA zip 02655 Country-_ Land Info Acres 0.35 I use Single Fam ,MDL-01- I zoning RC Nghbd 0105 Topography Above Street I Road Paved utilities Public Water,Gas,Septic I Location Construction Info Building i of 1 Year Roo f t 1979 Gable/Hip I Ex Vertical Sidin Built -. Struct - Wall Living 1325 Roof Asph/F GIs/Cmp '� AC None I '" Area Cover Type z W D K',';. w Int Style Cape Cod I. Wall Drywall Roomds 3 Bedrooms I �a - 1p ,i3z: Int Model Residential I or Wide Pine Bath Flo or 2 Full �. DAs Rooms I'd < in 7QS„ 19 BAST. - Heat Total 7o Grade Average Plus I Type Hot Water I Rooms 6 Rooms oMr 24 Stories 1.75 I Heat Oil Found- poured Conc. - Fuel ation -. Gross 2462 Area Permit History http://issg12/intranet/propdata/PareelDetail.aspx?ID=9541 12/31/2012 - o �� ��� %� COMMONWEALTH OF MASSACHUSETT'S b EXECUTIV' OFFICE OF ENVIRONMENTAL AFFAIRS � i r3'DEP�ARTM►ENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 53 Cantain`Alden Lane Ostewille MA 02655 Owner's;Name: Dori Hamant l!� Owner's Address: Date of Inspection:. November 14 2012 Name of'Inspector: (Please l i;iit) James M Ford Company Name: James_M. Ford Mailing Address: Osterville,MA 02655-0049 Telephone Number: (508)862-9400 ; CERTIFICATION STATEMENT I certify that I have personally inspected the•sewage'disposal system at this address and that the information reported: below is true,accurate and complete as of the.time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP ' approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15,000).. The system: . Passes Conditionally Passes ` eeds Further Evaluation by the.Local Approving Authority .ails f Inspector's;Signature: Date: November 29. 2012 The system.inspector shall sub i a copy f this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of comple ' &.this insp'ection..If the system is a shared system or-has a design flow of 10,000 gpd or greater; the inspector and the.system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,'and the approving authority. Notes and Cominents ***This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does uof address how the system will perform in the future,under'the same'or different conditions of use. 11. Title 5InspectionTonn, 6/15/2000 page I` Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAG E DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 53 Captain Aldens Lane Osterville MA' Owner: Dan Hamant Date of Inspection: November 14 2012 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates.that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304.exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the.Board of Health,will pass. Answer yes,no or not determined(Y;N,ND)in the for the following statements. If"not determined",please explain.. The septic tank is metal'arid::over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if•it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years,old is available. ND explain: Observation°of sewage backup or break out or high static water level in the distribution_box due to broken or obstructed pipe(s).or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are.replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A T, ,CERTIFICATION (continued) Property Address: 53 Caytain.Alderts Lane Osterville MA Owner: Dail Hamant Date of Inspection: November 14 2012, C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the.environment. 1. System will pass unless Board of Health determines in accordance with 310.CMR 15.303 (1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is.functioning in a manner that protects the public health,safety and environment: The systemhas.a septic tank.and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply on.triNtary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a pubtic.water supply. The system has s' tic tank and SAS and the SAS is within 50 feet of a private water supply well. The system Has a septic tank and SAS and the SAS is less than.100 feet but 50 feet or more from a private water'supply well**:'Method used to determine distance *This'system passes if:the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal.to or less than 5 ppm,provided that no other failure criteria`are triggerefli A copy of the analysis must be attached to this form. 3. Other: 3 I i Page 4 of 11 OFFICIAL:INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 53 Captain Aldens Lane Osterville.MA Owner: Dan Hamant Date of Inspection: November 14 2012 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ✓ Static liquid level in the.distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than%z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number . of times pumped_. ✓ y portion,of,the SAS;cesspool or privy is below high groundwater elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but.greater than 50 feet from a private water supply well with no acceptable water quality,analysis: [This system passes if the well water analysis; performed.at`a:D.EP..c'ertified laboratory,for coliform bacteria and volatile organic compounds ay indicates tliat:theell is free from pollution from that facility and the presence of ammonia nitrogen.and.nitratemitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)The system'fails 'J have°determined that one or more of the above failure criteria exist as described in 310 CMR 15;303.,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large. System' :•.:.i To be considered a large;system''flie system must serve a facility with a design flow.of 10,000 gpd.to 15,000 gpd. You must indicate:either"yes"or"no"to each of the following: (The following criteria apply io large:systems in addition to the criteria above) Yes No the system is within 400:feet of a surface drinking water supply the system is within:200 feet of a tributary to a surface drinking water supply the system'is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II,of a public water supply well If you have answered.".yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in Section D,above thelar&system has failed. The owner or operator of any large system considered a significant threat under Section:E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304: The system owner should'contact the appropriate regional office of the Department. i 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 53 Captain Aldens Lane Osterville MA Owner: Dan Hamant Date of Inspection: November 14 2012 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping.information was.provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as builtplans'ofkthe system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ — Was the site inspected for•signs of break out? ✓ Were all systeftitomporients,excluding the SAS,located on site? ✓ °Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disp6 1 systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ i;xisting-information:'-For example,.a plan at the.Board of Health. Determined in.the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. , , 1. . .. . . :f 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: . 53 Captain Aldens Lane _ Osterville.MA Owner: Dan Haniant Date of Inspection: November 14 2012 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based:on 310 CMR 15.20`(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): . .No . Is laundry on a separate sewage system:(yes or no): n/a [if yes separate.inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or.no): No Last date of occupancy: House was just vacated COMMERCIAL;%INDUSTR1Ali' Type of establishment, Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or:no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged.io`ihe Title 5 system(yes or no): Water meter readings,if available:'; Last date of occupancy/use:..' OTHER(describe): GENERAL INFORMATION Pumping'Records Source of information: l:Ptihiyed.3 pears aQo=per owner Was system pumped as:!part of the inspection(yes or no):_ No If yes,volume pumped: gallons_=How was quantity pumped determined? Reason for pumping:'•`! r TYPE-OF SYSTEM i :; ✓ Septic:tank;:distribution box,..soil absorption system 'Single cesspool ..._:_'i.r_::_': Overflow,cesspool %Share&system(yes_or no).._(if yes,attach previous inspection records,if any) Innovative/A lternative'technology. Attach a copy of the current operation and maintenance contract(to be obtained from°system owner) :Tight Tank Attach a copy of the.DEP approval Other(describe); I Approximate age'ofall components,date installed(if known)and source of information: Installed on 818179.,per as built card Were sewage odors:detected when arriving at the site(yes or no): No 6 t Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 53 Captain Aldens Lane Osterville ftA Owner: Dan Hamani Date of Inspection: November 14 2 112 BUILDING SEWER(locate on site plan)' . Depth below grade: Materials.of construction: _cast iron 40 PVC other ex lai ( p n)• Distance from private water supply.well or suction line Comments(on condition.of joints,venting;.'evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade:. 14" Material of construction', ' vilh concrete' � ' "metal —fiberglass —polyethylene _other(explain)..? s, :t ., ;Y. If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no certificate) ) (attach a copy of Dimensions: 1000 gal, Sludge depth: 1" ! Distance frorii Itop of sludge.to.liottoi-h of,outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum.to.16.g of outlet,.tee or baffle: 6" Distance'from bottom of scunit.o.botiom'of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Continents{on'pump'i'ng recoiniriendatibns,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,,evidence of leakage,etc.): Cenzeiu tees iver e resent The...liquid level was even with the outlet invert. There did not appear to be any si ns of leaka e. GREASE TRAP: ;alone' .(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene _other (explain ........... ... Dimensions: Scum thickness: ! Distance-from it top`of-Scum:to..top' of outlet tee or baffle: Distance from bottom of scum.to:bottom of outlet tee or baffle: Date of last purriping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related.to outlet`invert,.evidence of leakage,etc.): I, Page 8 of 11 ° . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM.INFORMATION (continued) . Property Address:. 53 Captain Aldens Lane Osterville,MA Owner:. Dan Hamant Date of Inspection: November 14`2012 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: allons Design Flow: gallons/day`' Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of'alarin`'a'nd`float�s''i h es,etc.): DISTRIBUTION BOX:. ✓ (if present must be opened)(locate on site plan) i Depth of liquid level above outlet invert:;' .::Even Comments(note if box is leve'l'aiid.distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or'outlof box,etc':):-_i_ The D-box was even. No solids ivere Present. PUMP CHAMBER: None.- (locate on site plan) .i. Pumps in working order(yes_or Alarms_in working.order(yes orno)..:::_:.. . Comments(note condition.of pump chamber;condition of pumps and appurtenances,etc.): i Page 9 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION (continued) Property Address: 53 Captain Aldens Lane Osterville MA Owner: Dan Hamant Date of Inspection: November 14,-2012 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 - 6'x 6'(1000 gal)w/1'stone per design plans leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number' Imiovative/altPmatwe systeji_ .:.,Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit was full The liquid was tip into the inlet pine The pit is in failure The bottom to grade was 8' A tamer a was used or the ins ection CESSPOOLS: None (cesspool mugt be pumped as part of inspection)(locate on site plan) I Number'a nd-configuration: Depth-top of liquid to inlet invert: Depth of sol ds•laver` Depth of scum layer:- Dimensions of cesspool: Materials of coiistr'uctioni l 1! Indication of groundwater.iriflow(yes..or.no)` Comments. (note„condition of soil;.signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i PRIVY: None, (locate-onSite plan) .. Materials ofconstructiorir • `: :,:i;: Dimensions 1;; Depth of solids:' Comments(note.conditiori of soil;signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 ' Page 10 of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 53 Captain Aldens Lane Osterville'MA' Owner: Dan Hamant Date of.Inspection: Novenrber•�14 2612 SKETCH.OF SEWAGE DISPOSAL SYSTEM Provide a sketch.of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all.wells within 100 feet. Locate where public water supply enters the building. I rOAT aob rY «4 !� 0; ri. t 10 Page 11 of 11l . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INNSPECTION FORM r . PART C SYSTEM INFORMATION(continued) Property Address: 53 Captain Aldens Lane Osterville ILIA `. Owner: Dan Harnant Date of.Inspection: Novenrber.14 2012 SITE EXAM Slope Surface water Check.cellar Shallowrwells Estimated depth to ground water. 25 +`7- feet Please indicate (check) all methods used todetermine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting,property/observation hole within 150 feet of SAS) Checked wi"thlldcal Board of Health=explain: topograyhic and water contours maps Checked with ocal excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how.you established the high ground water elevation: _UsillQ Barnstable'topogr aphtc and water contours maps the maps were showing approximately 25'+/ to ground water at this site. ki This report has been prepared,ortly for the septic system and components described herein. 'This septic system has been inspected arrd failed as.of.:the date of inspection. This report is not'a warranty or guarantee that the system will f nrction properly in the f nitre., There have been no warranties or guarantees,either expressed, written or implied, relating to the septic'systent, the inspection;this report and/or any components of the septic system which have not been located and inspected i� - 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AF AIRS z`�s+ DEPARTMENT OF ENVIRONMENTAL PROTE TIONi a 'N fn TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSES MENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 53 Captain Alden Lane Osterville. MA 02655 Owner's Name: Tom&Mary Kilcovne ��33 Owner's Address: 314 Date of Inspection:. October 17, 2005 Name of Inspector: (Please Print) Janes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number:. (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs F rther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: October 23, 2005 The system inspector shall sub it copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completi g this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the.appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments **"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 53 Captain Aldens Lane Osterville. MA Owner: Tom&Mary Kilcovne Date of Inspection: October 17, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 53 Captain Aldens Lane Osterville. MA Owner: Tom&Mary Kilcoyne Date of Inspection: October 17. 2005 ' C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh . 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 53 Captain Aldens Lane Osterville, MA Owner: Tom&Mary Kilcovne Date of Inspection: October 17, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_.. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 53 Captain Aldens Lane Osterville, MA Owner: Toni&Mary Kilcoyne Date of Inspection: October 17, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. _ ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 53 Captain Aldens Lane Osterville, MA Owner: Tom&Mary Kilcoyne Date of Inspection: October 17, 2005 .FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 5 weeks ago-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 818179-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 53 Captain Aldens Lane Osterville, MA Owner: Tan&Mary Kilcovne Date of Inspection: October 17, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 14" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _,other(explain.) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1 G'00 Qa1. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: _Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were Present. The liquid level was even with the outlet invert There did not appear to be any signs ofleakaQe GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 53 Captain Aldens Lane Osterville, MA Owner: Tom&Mary Kilcovn_e Date of Inspection: October 17, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Commments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The D-box was even. No solids were Dresent. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ 53 Captain Aldens Lane Osterville, MA Owner: Toni&Mary Kilcovne Date of Inspection: October 17, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: - 1-6'x 6'(1000 eaL)w/1'stone-per design plans leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The pit had 4'oflipuid on the bottom The scum line was approximately 5'up from the bottom There did not appear to be any signs o ailure. The bottom to grade was 8' CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration- Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool-. Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 i� A Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 53 Captain Aldens Lane Osterville, MA Owner: Tom&Mary Kilcoyne Date of Inspection: October 17. 2005 t SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. pe 3 a � y Aa 3 al a� i y ace 3a 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 53 Captain Aldens Lane Osterville, MA Owner: Toni &Mary Kilcoyne Date of Inspection: October 17, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours ingps, the snaps were showing gggroximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. ' 11 TOWN OF BARNSTABLE -ATIU��i C� I SEWAGE # I-AGE D S�L(v� ASSESSOR'S MAP & LOT L/ " 0 e� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY lU n LEACHING FACILITY: (type) 1',T �X6 (size) / STDe NO.OF BEDROOMS BUILDER OR OWNER T � C DY/V, PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching.Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ::L—: t't)� 1 A i 'IT y a� Pa l CA`TION SEWAGE PERMIT NO. 5a�,P =N 'I L l AG E INSTALLER'S NAME & ADDRESS BUILDER . OR OWNER DATE PERMIT ISSUED _ �_`3-71 DATE COMPLIANCE ISSUED t. �r �C 2 loco�eAfT 10N S E W A�j ^PERMIT NO. / vas VILLAGE f I N S T A LLER'S1 NAME b ADDRESS RUILDER�--O-0R OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED f AJ T , L A J No...�.��. Flcs...... ��... ~ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH oil " OW.-N.-- .--......OF...- . 'h1. 19.. �.. ............................ rA Appliration for Disposal Works Tonstrurtion Vnmit Application is hereby made for a Permit to Construct (kl�or Repair ( ) an Individual Sewage Disposal System at: ............41-J0.7.....Zo......................................................... Location-Address r Lot No. f7 C : -------_..?� �� X f o l�c��PYII/.�%...... ILS S...... caner, ............................................Address ............... ... ............................ ..........:... Installer Address Type of Building Size Lot./ .®Q Q...._..Sq. feet U Dwelling—No. of Bedrooms.......... ...........................Expansion Attic ( ) Garbage Grinder (40) '4 Other—T e of Building ........ No. of persons............................ Showers — Cafeteria a Other fixtures •. ........... ... -.. ..- w Design Flow......l.ee...........................gallons per ePday. Total daily flow.........�.O..................gallons. W Septic Tank—Liquid capacity/0"..gallons Length.W..__.. Widths/.±.2Q`' -..'. Diameter................ Depth Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... ........... Diameter..-G .......... Depth below inlet•-<5.._......... Total leaching area`.-0:6...sq. ft. Z Other Distribution box ( "�_ Dosing tank ( ) Percolation Test Results Performed Date.....N.O.U.:.. �._Lg�8 �a Test Pit No. Le,'-_ :._..minutes per inch Depth of Test Pit./a....... Depth to ground water..- .t?�V -. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -•••••----••----•-•-•-•-•••.................•••-•-•--...-------•••----................---...............-•---•--------------•-----.....---------------.•---- 0 Description of Soil........ ........A.A�J>-----•,�1.� �0 ------------------------------------------------------------- x ...=ice.-----��_ Vi._.A - - ------------------------ c, ••-------•---••-••••-•••-•-•-----•-- w VNature of Repairs or Alterations—Answer when applicable........................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sigd ...-- .----•-•••................................•--------••--•--------- D to Application Approved B Date Application Disapproved for the following reasons:---------•-•--- - ----- -•-•-------=-•----------•------•--•---•-----•-----•....................•--•.... ........................................................................................................................................................................................................ p Date Permit No......................................................... Issued..:::" - -�-••Z�•...---•---•--....--- Date d THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Dispaii al Works Ton,itratrtinn Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: Location Flo Address r 1? t' ........................... d ? ��--��t°...'t� Wner Address ---••- ------•----•-• -------••••- --------•.................. ......... ..... ...... � Installer Address Type of Building Size Lot.i.50040.......Sq. feet DwellingNo. of Bedrooms__._ _._ Ex ansion Attic — --- P ( ) Garbage Grinder ( #), p., Other—Type of Building ................... No. of persons._........................... Showers ( ) Cafeteria ( .. P4,. Other fixtures --- --- Q .... •• --_... W Design Flow...../` ,Gt�_..........................gallons per- ` per day. Total dailyflow....._ �. ..................gallon. WSeptic Tank—Liquid*capacityllJ`"..gallons Lengthd?..44L_-.. Widths $. . Diameter................ Depth.. _. _..:. x Disposal Trench—No..................... Width.....___....._.._ . Total Length.................... Total leaching area...................sq. ft. Seepage Pit No......�----------- Diameter...46....__.... p Total leaching areae ...sq. ft. . Depth below inlet_...4�,r+............. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by.. !4 ?. 4.4.7?._/.t.C1'1F"" ____ _ ,.___ Date_..... a Test Pit No. 14+ .A-____minutes per inch Depth of Test Pit./A.......... Depth to ground water..:? Qi+�✓ __. (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•---....... -----•--•-••--•-----•-•---•...•---•..._..... ••.......---•--......•---•-.•-•-••-••--••--•••--..................................... O Description of Soil.......C2.� AL..2- ..........A,4 ert t', 'r -----•--•--------------------------•--------------------------- U ......-------•• -..... •. .elenemww....... lit.. --• ---------•-------------------------•------....----.....-----..........._ U W UNature of Repairs or Alterations-Answer ;when applicable______________________: :_ ..-• ••••------•••-••----••••-•------•---•--••-•-•----•----••••-••-----•-•••--•---•--•--------------------•-•....................----••-••-••-••-•---•--•-•-----••... Agreement: The undersigned agrees- to install the aforedescribed Individual Sewage Disposal System i�ri accordance with the provisions of'TTLI, 5 ofut State.Sanitary Code—The undersigned further agrees not tfo place the system in operation until a Certificate of Compliance has been issued by the board of health. ��'' Sigd' 1 � ..-.... Application Approved By-- -•' `l.'•.. • - ... ................... 91...-- .' Date Application Disapproved for the following reasons:- ......•.... ; '.............................................................. ;` � ---------------------•-------------.....----------------..........-------••-------.....----•------... : ----• -- -•---•----•--•------------•--------------•--•------- --------------------••------- Date PermitNo......................................................... Issued..............................................:........ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ptiS�.M.................OF......... tt!Y.. A).S.ZK.&K e.......................... (Urtifirate of T;amp itanrr THIS IS TO CERT Y, Tha thq Inv vid ewag Disposal S stem constructed ( or Repaired ( ) by........................................ 1 !✓..... -----..... .-- ---.....------ ........ ------.......-•--------------•----- �„ „ ` Installer A at has been installed in accordance with the provisions of T ' a of The State Sanitary Code as described in the application for Disposal Works Construction Permit No _.••.....WU............. dated.....__ �'-�_�_ �. '. - THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WIL FUNCTION SATISFACTORY. DATE......... ---•--•--------------------•----••--..............._•-----........... Inspector•• /� (. " g4 THE COMMONWEALTH OF MASSACHUSETTS .-�-- BOARD OF HEALTH ....... .r.�'....1144..........OF........ 412..j.V .S.%.. .f.1 -If'..r.................... �i��n��a1 nrk� �,nn�tr,� tmrn rrutit Permissionis hereby granted............................................................................. ..................................................... to Construct ( or Repair C. ) an Individual Sewage Disposal System atNo.....4 42X _.14)......... ...-•--e-Al....------.4 . . ' '"f .t l' :_ ............................................................ Street as shown on the application for Disposal Works Construction Permi o....____ Afeafth q oar DATEf ...................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS J LEGEND" OSTERMLLE --�---1 PROPOSED CONTOUR ° PARCEL ID: a o z 146/047 ® PROPOSED SPOT GRADE cc 0 EXISTING CONTOUR o + 96.52 EXISTING SPOT GRADE m 4�F'QT v v 3 V -9 W— EXISTING WATER SERVICE �T PARCEL ID: LOCUS #53 1V ® TEST PIT o CAPT. 146/085 tp ALDEN'S ul AREA=I.5,000f S.F. �I-Q. ROUTE 28 LANE N OAK PARCEL ID: 146/086-001 F --i OA� • PINE LOCUS MAP PARCEL ID: RS AK �Q LOCUS INFORMATION 146/048 PLAN REF: LCP 34625-8 �O G AK c3` TITLE REF: CTF#178911 $ 0 PARCEL ID: MAP 146 PAR. 85 ZONING: "RC" PINE \ 40AK FLOOD ZONE: "C" OAK�� 4 k ( COMMUNITY PANEL- 250001-0015—C DATED:08/19/85 2-K _ SEPTIC SYSTEM ` - REPAIR PLAN OA ce/DH __ - #53 ! ,TOF=53.16 LOCATED AT: EXI5TING LEACH PIT �� - - -_ c�q 53 CAPTAIN ALDEN'S LANE (see note I O) --- __ _ _ - -= _=- - �f' ,� /�. -' - OSTER VILLE, MA. _ - 4 qy 4 �/48'0 PREPARED FOR COR J, lr@M=-53.52STEP /' ,, DANIELS & DEBORAH E. Xse ticOtton ,- ��� i �y° ; GENERAL NOTES: H AM AN T " \ W '� 16� 49.0 DECEMBER 18, 2012 Q 1.0 1O j� 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL Oe OAK 4" �' / 449.10 BOARD OF HEALTH AND THE DESIGN ENGINEER. 14" H LY \ moo' l 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS q�p G OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE OF PINE ?fb�152 14 \ Hl �V LOCAL RULES AND REGULATIONS. / r' OAK ( 0.0 'P 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFIU.ED PRIOR g A� N _ TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE AAAttt��� PARCEL ID: ' ti �,.�' , DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 146/084 �Q � 112" �Q + FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 00 - OAK r� / 0 ('1 MAGNAIL ENGINEER BEFORE CONSTRUCTION CONTINUES. EL=49.10 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF $A►ITAR1a Q P \ r. THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF E �� / OG�OF (� HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. PIN ^ r 1 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. a.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 1.0 UPOLE 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY CB/DH THE LOCATION CONSTRUCTION.OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING MEYER & SONS, INC. K J /� 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE V. p X 981 5�V 40 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION P . 'O O 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY EAST SANDWICH, M A. 02537 AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO OTHER PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING 14. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPEC.) (508)36 2—2 9 2 2 I 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW ! FOR THE USE OF A GARBAGE GRINDER 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING SCALE: 1"-20' SHEET 1 OF 2 J 1497 NOTE: TO PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:49.16 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER INSTALLED T.O.F. EL.=53.16 OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. ENGH F.G. EL.=52.0f F.G. EL.=52.0f F.G. EL:52.0t F.G. EL: 52.0(MAX.) Svc Of �SS9 /- 9.45" A R �y L te't 9""MIN COVER/ " N 1140 36 MAX COVER L m 32' L = 10'(MAX INSTALL TWO INSPECTION PORTS (MIN.) 12.37" 0 S®1 X (MIN.) ® Sm I X (MIN.) ® S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC LLj10 a 10.75" TO NITAR�p� INV.= 49.95 48'Uclao 1` INV.=49.70 INVERT COUPLER DETAIL LEVEL INV.= 48.70 GAS BAFFLE PROPOSED 4 ROWS OF 5 UNITS ® 5'/UNIT = 25'/ROW BOX M AM INV.=49.38 �_� 49.2o SOIL ABSORPTION SYSTEM (PROFILE) EXISTING 1.000 GALLON SEPTIC TAN EXISTING OUTLET I - RESTORE VEGETATIVE COVER BACKFILL WITH CLEAN PERC SAND 60" NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING TO TOP OF CHAMBERS PIPE INVERTS PRIOR TO CONSTRUCTION 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV.=49.16 GRADE ON A MECHANICALLY COMPACTED SIX INV. ELEV.= 48.70 INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2) BOTTOM ELEV.= 47.83 EXISTING SUITABLE 3) REPLACE EXISTING 1,000 GALLON SEPTIC 2•�' MATERIAL TANK WITH 1500 GALLON SEPTIC TANK 5' MIN. ABOVE BOTTOM OF IF FAILED, DAMAGED, OR UNDERSIZED. T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH 4 x 2.88' 11.52 4) INSTALL INLET & OUTLET TEES W/ ZABEL (7.03 PROVIDED) USE 4 ROWS OF 5-ADS ARC 36HC . FILTER AND GAS BAFFLE AS REQUIRED BOTTOM OF TESTHOLE EL.=40.80 ' (H20) UNITS - NO STONE SEPTIC SYSTEM PROFILE TYPICAL SECTION , N.T.S. 16"Krs SOIL LOG P#: 13821 DESIGN CRITERIA DATE: DECEMBER 17, 2012 SECTION 1075. SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE. #1614 INVERT NUMBER OF BEDROOMS: 3 BEDROOM DESIGN WITNESS: DON OESMARAIS, BARNSTABLE BOH HEIGHT END CAP SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 330 G.P.D. 5 80 TP--1 a Elev. TP-2 Depth ADS - ARC 36HC CHAMBER (H20 LOAD) GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) 51.80 0" MODEL ARC 36HC SEPTIC TANK: 330 gpd x 2009E = 660 gpd USE EXIST. 1,000 GALLON SEPTIC TANK LOAMY 1 3/2D 12" I YYR LOAMY �D LENGTH 63" NOTE: UNIT CONFIGURATION AND AVAILABIUTY SUBJECT 50.80 B % 50.80 B 12" EFFECTIVE LENGTH 60" TO CHANGE ASUGWITHOUT IT UT FROM ACTUAL PRODUCT DETAIL MAY APPEARANCE. LOAMY SAND LOAMY SAND SIDE WALL HEIGHT 10.75" LEACHING AREA REQUIRED: (330)/0.74 445.94 S.F. 48.71 37 10YR 5/8 " 1OYR 5/8 OVERALL HEIGHT 16" DISTRIBUTION BOX:, 4 OUTLETS (MINIMUM), C MEDIUM- 80 C MEDIUM- 36 OVERALL WIDTH 34.5" 4640 TRUEMAN BLVD PRIMARY S.A.S. COAL SAND COARSE SAND 10.7 CF H/LUARD, OHIO 43026 5 - ADS ARCHC 3616 H20 UNITS-NO2.5Y 7/4 2.5Y 7/4 CAPACITY (80.0 GAL) ADVANCED orulNACE srsrEMs. INc. PERC • 47,30 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF CHAMBER) 0 PROPOSED SEPTIC SYSTEM SITE PLAN (CHAMBERS: 5/ROW)20 UNITS X 5.0 LF x 4.80 SF/LF = 480.00 SF 40.80 13 1 40.80 i32" 53 CAPTAIN ALDENS LANE, OSTERVILLE, MA TOTAL AREA = 480.00 SF PERC RATE<2 MIN/IN. ("C2" HORIZON) Prepared for: Homant' DESIGN FLOW PROVIDED: 0.74GPD/SF(480.OSF) = 355.20 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN MEYER&SONS,INC. AfaoDougsH survey NTS D.M.M. • 1, Done. M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 pOBOX881 (508) 419-1086 DATE: CHECKED -- to conduct soli evaluations and that the above analysis has been performed by me consistent with the E48TSANDMCH AfA0=7 SHEET N0. requirements of 310 CMR 15.017. 1 further certify that I have passed the Sall Eval. 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